Provider Demographics
NPI:1225193253
Name:RUSCO, VALERI A (PAC)
Entity Type:Individual
Prefix:
First Name:VALERI
Middle Name:A
Last Name:RUSCO
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:VALERI
Other - Middle Name:A
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1111 LEFFINGWELL AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-6406
Mailing Address - Country:US
Mailing Address - Phone:616-459-7101
Mailing Address - Fax:
Practice Address - Street 1:230 MICHIGAN ST NE
Practice Address - Street 2:SUITE 300
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2550
Practice Address - Country:US
Practice Address - Phone:616-459-7101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004845363AM0700X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00398254OtherRAILROAD MEDICARE
MIP00398254OtherRAILROAD MEDICARE
MIQ75705Medicare UPIN